HESI - Medical Surgical Nursing testExam TEST BANK FOR MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS

A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? A) "The hospital requires that all inpatients be weighed daily." B) "Weight is the best indication that you are gaining or losing fluid." C) "You need to lose weight to decrease the incidence of heart failure." D) "Daily weights will help us make sure that you're eating properly." - correct answersB Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. A client has a deep wound covered with a wet-to-damp dressing. Which intervention does the nurse include on this client's care plan? A) Apply a new dressing when the seal breaks and the dressing leaks. B) Change the dressing when the current dressing is saturated. C) Leave the dressing intact until next week. D) Change the dressing every 6 hours around the clock. - correct answersD Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum débridement. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate is leaking. Dry gauze dressings should be changed when the outer layer becomes saturated. A client has a small-bore nasoenteric feeding tube. The nurse assesses the following vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and blood pressure, 106/62 mm Hg. Which action by the nurse takes